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Llehman@ecmc.edu

Verbal Orders for Blood/Blood Products

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Question for ALL Blood Bankers:

Do you ever accept Verbal Orders for Blood Blood Products (specifically in emergencies)?

This has been a lively discussion in our facility. I quoted AABB Standard 5.11.1, where the last sentence reads: "The transfusion service shall accept only complete, accurate, and legible requests", but other Departments want to know what other facilities in the country are doing. I would greatly appreciate your responses. Thank you.

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We will begin TS by verbal order but do not thaw FFP or issue any product on verbal order. In fact had an MD come to blood bank for unit of blood and would not give it until he wrote and signed order on sheet of paper which was put on chart.

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(Unfortunately), I can't say it has never happened, but our policy is that we must have a computer order (or a handwritten order if the computer is down) to issue blood (whether it is crossmatched or uncrossmatched.) During my career I have seen transfusion errors involving similar names (such as "Marion" and "Marianne"), two patients with the same unusual name on the same nursing unit, and accident victims in the Emergency Room involving family members with same or similar names.

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The only time we perform any work without a written order is when the OR is in the throws of chaos. We have one person in the OR who is delegated ot comunicate with the blood bankfor all orders . I will order platelets for Oncology before I get the written order.

Just yesterday when a nurse came to pick up some blood on a patient, I gave her my sweetest smile and said that I would be glad to get it ready after I got the order.

Sorry about running on like this! Can you tell that I have been working by myself all day?

:flirty::flirty::flirty::flirty::peaceman: Have a wonderful weekend!!!!!!

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We accept verbal orders during emergency situations- trauma or OR. This generally happens with uncrossmatched for trauma or OR patients who start massively bleeding and we run out of what was originally set up. We try to get a computerized order but will not delay getting product to the patient if we can't get immediate compliance from nursing.

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We accept verbal orders during emergency situations- trauma or OR. This generally happens with uncrossmatched for trauma or OR patients who start massively bleeding and we run out of what was originally set up.

Same here. Our ER is good about signing releases after the chaos has calmed down.

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We accept verbal orders during emergency situations- trauma or OR. This generally happens with uncrossmatched for trauma or OR patients who start massively bleeding and we run out of what was originally set up.

Same here. Our ER is good about signing releases after the chaos has calmed down.

and expecting the doctor to come to bb afterwards? what if it is next to impossible? no verbal request allowed?

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and expecting the doctor to come to bb afterwards? what if it is next to impossible? no verbal request allowed?

We hunt them down if we need to. If I'm working, I go to ER myself once things have calmed down. I've sent a pathologist into the surgeon's lounge after them. I've mailed them to the office marked URGENT with a letter requesting that it be signed and returned ASAP. If mailed and no response, I call the office manager to nudge them. I've never had a big problem getting the forms back (I do keep a copy, just in case). Our surgeons are actually quite good about compliance issues. We are thankful for that!

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Verbal orders only for emergency uncrossmatched (we bring a form for MD to sign) or to get a massive transfusion protocol started (they do have to order the protocol in the computer after the fact).

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We used to accept verbal orders from the ER and OR but are changing our policy. We will be requiring the OR to put something in the computer or use a manual form with patient label on it. The ER will be using the same form unless it is ER release. This is due to a recent citation given by CMS [Medicare inspection] that inspected charts from OR patients, found the transfusion slips on the chart but NO ORDERS TO TRANSFUSE!

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Okay here is sort of a devil's advocate question.  I am in the process of getting an MTP protocol in place, and the first plan was to have verbal orders, but after reading the standards, this is not going to work.  What if the circulating RN (our BBK contact during an MTP) calls down, identifies the patients namen MRN and blood bank wrist band number, rattles off what they want blood wise, and then our point person in the BBK actually writes the request?  At the end of the catastrophy, can we have the circulating RN initial all of the requests then to signify that they were ordered by a designated health care professional?

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For our MTP protocol, we start packing and sending coolers and product based on an established protocol that has been signed off on as policy by our trauma director, pathologist, ER, OR, etc. 

 

In fact, in order to get our Trauma Level 2 certification from the ACME trauma certification agency (or whatever), we had to have all of these types of policies in place and part of the policies for MTPs.  The point being that ER or OR does not have to worry about ordering specific product at all--once the MTP is initiated, we keep supplying coolers based on the protocol unitl the MTP is called off.

 

Scott

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For MTP we have them first start off with emergency release uncrossmatched. We take the 2 units of type O immediately and then ask them for a 2 unit transfuse order to be placed after the fact to document it.

Then when they decide they need the MTP we have them order it in the HIS also. We start the MTP on the verbal order, but then nag them to put the order in.

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First, I would point out that Nursing accepts verbal orders from Physicians all the time.  I too  have worked places where we accepted Verbal Orders "for emergencies only;" but we had a Manual Form where we wrote down everything the caller was saying to us (including their name and the name of the ordering Physician).  We kept those documents.  At 1 Trauma Center I worked at, we just had an alarm go off in the dept. as an indication that the ER wanted us to bring over a Trauma Cooler (6 units of uncrossmatched RBCs).  That is even less than a verbal order....so sometimes, you just have to "do what you have to do" in an urgent situation.  Also worked at a place where a post-partum woman hemorrhaged to death on the Night Shift.  Labor and Delivery was sending erroneous orders in their urgency (i.e. Fresh Frozen Platelets....).  Perhaps talking with them on the phone and getting immediate clarificaiton, might have resulted in a different outcome; don't know.......  You have to follow regulations and you have to be safe....but you also have to be realistic and do everything possible to ensure a patient does not bleed to death, just because you do not have a writen order in hand.

 

Just my thoughts/experience.... :) 

 

Brenda Hutson

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An MTP is a protocol which is reviewed and approved in advance by some group of physicians in your organization.  As such, you can do whatever the protocol tells you to do as long as the protocol is ordered.  Our MTP states that we can provide products based on verbal orders (usually plts and cryo).  We also "keep ahead" RBCs and FFP and give them whatever they want next.

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You can fix paperwork, you can't fix exsanguination.  I repeatedly tell our staff not to let paperwork interfere with patient care.   While recognizing the value of correct, complete and timely records, sometimes you just have to shovel the red stuff out the door.

Edited by David

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Check out TJC RC.02.03.07 "Record of Care, Treatment and Services" - This section specifically deals with verbal orders.

 

CMS also talks about verbal orders. There's a point that you have to have record of date/time of verbal orders and that the orders have to be authenticated by the ordering practitioner or another practitioner responsible for the patient's care within a timeframe established by State law. The requirement used to be 48-hours for authentication but it was relaxed in 2012. It's somewhere in 42CFR.

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Our Policy allows for verbal orders for emergency situations, so long as they are followed up by written orders after the emergent situation is over. But we have to chase for paperwork to get completed - cry... coax.. cajole.... threaten.... plead... whatever... and not necessarily in that order.  :cries::please:  :angered:  :threaten:

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